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GENERAL
PHYSICAL EXAMINATION & CVS
GENERAL PHYSICAL EXAMINATION
General appearance
Young ( ) / Old ( ) Healthy ( ) /ill ( ) /anxious looking ( )
Physique
Normal ( ) Unusually tall ( ) Short ( ) Obese ( ) Thin ( ) Wasted ( ) Puffy ( )
Consciousness
Alert ( ) Oriented ( ) Confused ( ) Drowsy ( ) Unconscious ( )
Posture or Attitude
Comfortable ( )
Dyspnic
While lying in bed ( )
Lying propped up ( )
Sitting up or bending
forward ( )
Supraclavicular (
)\intercostal ( ) Indrawing ( )
In pain ( ) lying still
( )
Writhing in bed ( )
Any specific odor from patient
Fruity (acetone) ( ) Fetor Hepaticus ( )
Vital Signs
Pulse - Rate........ (per minute) Rhythm...........
BP ............... (mmHg) Palpatory.......... Auscultatory...........
Temperature ( ) F / C
Respiratory rate ................
Hands
Shape.................. Short metacarpals ( ) Syn ( )/Poly ( ) Dactyly
Tremors ( ) ............. Carpal spasm ( )
Size......... normal ( ) OR Broad ( ) Tattoo marks ( )
Nails
Pallor ( ) Clubbing ( ) Pitting of nails (
) Cyanosis ( ) Splinter hemorrhages ( )
Beau's lines ( ) Oncholysis ( ) Meas lines
( ) Jaundice ( ) Koilonychia ( )
Leukonychia ( ) Terry's nails ( )
Fingers
Oslers nodes ( ) Bouchard's nodes ( )
Heberdons's nodes ( )
Joint swelling ( ) Arachnodactyly ( )
Xanthomas ( )
Ulcers at the finger end ( )
Gouty tophi ( )
Palms
Pallor ( ) Palmer erythema ( )
Sweating ( )
Scratch marks ( )
Duputyren's contracture ( ) Asterixis ( )
Bruising ( )
Simian crease ( )
Janeway's lesions ( )
Face
General appearance- sallow appearance ( ) Moon like face ( )
Pink puffer ( )
Blue bloater ( )
Expressionless face ( ) Peaches &
cream appearance ( )
Pallor ( )
Periorbital puffiness ( ) Loss of outer
1/3 of eye brows ( )
Proptosis ( )
Ptosis ( ) Xanthelasmas ( )
Yellowness of lower conjunctiva ( )
Pallor of lower conjunctiva ( )
Yellowness of sclera ( ) Rash ( )
Bluish tinged sclera ( ) Hirsutism ( )
Alopecia ( )
Baldness ( )
Any vesicles ( )
Spider nevi ( ) Enlarged parotid gland ( )
Any abnormal pigmentation of the lips ( ) / Face ( )
Cheilosis (Lips) ( )
Angular stomatitis ( )
Tongue
Abnormally large tongue ( ) Dryness ( )
Pallor ( )/ Cyanosis ( )
Any abnormal pigmentation ( ) Loss of
papillae ( ) Redness ( ) <on dorsal
surface>
Yellowness ( ) <undersurface>
Neck
Thyroid
Inspection
..............................
Palpation
..............................
Percussion
(retrosternal thyroid) ..............................
Auscultation
..............................
Pamberton's sign
..............................
Neck vessels
Level of JVP
.............................., Venous pulsations ( )
Dancing carotids ( )
Carotid shudder ( ) Carotid bruit ( )
Lymph nodes
Submental ( )
Submendibular ( )
Parotid ( )
Pre auricular ( )
Post auricular ( )
Ant /Post cervical ( )
Occipital ( )
Supraclavicular ( )
Scalene nodes ( )
Lymphnode
Features:
No .......... Site .......... Size .......... Consistency ..........
Mobility.......... Matted .......... Discrete ..........
Adherent to Skin .......... (Adherent to underlying structures) .......... Tenderness
..........
Discharge .......... /Sinuses ..........
Breast examination
Right
Symmetry .......... Localswelling ..........
( describe features of a mass) see the box below
Left
Symmetry .......... Localswelling ..........
( describe features of a mass) see the box below
Skin-dimpling or Teathering ( ) right ( ) left
Nipples-Retracted ( ) ( )
Discharge ( ) ( )
Axillary tail ................... .....................
Regional lymph nodes
Axillary ................... .....................
Supraclavicular ................ .....................
Axilla
Axillary hair ..................
Lymph nodes Ant ( ) Post ( ) Lat ( ) Med ( )
Apical ( ) Central ( )
Groin
Pubic hair .....................
Inguinal lymph nodes ( )
Testicular atrophy ( )
Presacral edema ( )
Hernial orifices...............
Shin
Ulceration ( ) Abnormal pigmentation ( )
Loss of hair ( )
Feet
Clubbing ( ) Koilonychia ( ) Cyanosis ( )
Loss of hair ( ) Edema ( ) Interdigital clefts---Athelet's foot ( )
| Features of a mass Site.............. Size .......... Shape ............ Consistency------ Cystic ( ) Soft ( ) Firm ( ) Hard ( ) Surface----- Smooth ( ) Irregular ( ) Nodular ( ) Edge ......... Tenderness ( ) Movement with respiration ( ) Mobile ( )/ Fix ( ) limits ........... Bimanuallypalpable ( ) Thrill ( ) Transillumination ( ) Pulsatile ( ) Skin fixation ( ) Fluctuation ( ) |
CARDIOVASCULAR SYSTEM
Pulse
Rate ........... Rhythm ........... Vol ........... Character ...........
Condition of vessel wall ...........
Comparison with other pulses...........
Radio radial delay ( ) Radiofemoral delay ( )
Other features
Dancing carotids ( ) Pistol shots ( ) Capillary pulsations ( )
Digital throbbing ( ) Auscultation of major arteries any bruit ( )
INSPECTION
a) Chest deformity Pectus excavatum ( )
Pectus carinatum ( ) Scoliosis ( )
b) Scar on chest-sternal ( )
Lateral
Thoracotomy scar ( )
c) Pulsations
Apex beat ( )
Pulsations--- Along left para sternal border ( )
In-- pulmonary area ( ) Suprasternal notch ( ) Epigastrium ( )
d) Prominent veins ( )
PALPATION
1) Apex beat ........... a) site ........... b)
character ...........
Tapping ( ) Heaving ( )
Illsustained ( )/well sustained ( )
Normal ( )
2) Right ventricular heave ( )
3) Left ventricular heave ( )
4) Palpable heart sound ( )
5) Thrill ( )
6) Palpable pericardial rub ( )
7) Epigastric thud ( )
PERCUSSION
Area of cardiac dullness increased ( ) or
Decreased ( )
AUSCULTATION
Heart sounds
a) Intensity s1 ........... , s2 ...........
b) Splitting of s2 ( )
c) 3rd & 4th heart sounds ...........
d) Gallop s3, s4 ...........
Other sounds
Opening snap ( )
Ejection systolic clicks ( )
Mid systolic click ( )
Prosthetic valve ( )
Murmers
Timing ...........
Grade ...........
Site of max. intensity ...........
Radiation ...........
Character ...........
Pitch ........... Effect of
respiration ........... Effect of posture ...........
Pericardial rub ( )